VitalHub solution expands from Mount Sinai Hospital
TORONTO – A lot has happened at VitalHub since the company was spawned at Mount Sinai Hospital in 2009. The spin-off was among the first to provide access to a hospital’s clinical systems through the Apple iPhone, a device that has become wildly popular among doctors and nurses.
The start-up company has now set up shop at a high-tech incubator, the Digital Media Zone at Ryerson University, where it is led by a new CEO, Lisa Crossley. A PhD in chemical engineering, Crossley is a three-time CEO and has raised over $30 million in angel and venture financing from investors in the U.S. and Canada for her companies.
Since joining VitalHub in October 2011, she has proceeded to attract over $1.6 million to the company, providing it with the working capital needed to support its current Canadian deployments and to begin to penetrate the US market.
The VitalHub system is now available on iPads, a device that’s favoured by physicians because of the larger screen size, and an Android version is under way.
And in addition to users at Mount Sinai Hospital, a pilot project involving 50 clinicians is now in progress at London Health Sciences, in London, Ont. Another pilot was started in February with the BC Cancer Agency and the BC Provincial Health Services Authority that also involves Apple and IBM. A go-live is planned for June, and if all goes well, the system will be rolled-out throughout the province of British Columbia.
“BC looked at other solutions, but none of the others was satisfactory,” said Crossley. “They decided on VitalHub, in part because of the speed of our system.”
She noted that speed of access to computerized data is a critical factor. “Physicians won’t stare at their hand waiting for data for more than two seconds,” she said, explaining they’re just too busy. However, VitalHub impresses them with its almost instantaneous delivery of information. “It’s our secret sauce,” she quipped.
In addition, VitalHub makes use of a ‘virtual’ architecture for accessing information. Instead of consolidating information from different data silos in a large repository, which some mobile access systems do, VitalHub accesses information from the various departmental and corporate servers in real-time, on an as-needed basis. It can also write information back to the servers, so that files and charts are instantly updated.
This makes it much easier to implement, as no additional data centres are needed. That in turn brings down the cost.
On the topic of cost, Crossley noted that VitalHub is charging just $25,000 for its server configuration, which ties into the existing servers and repositories of customers. It usually sits on the hardware that’s already owned by the end-user.
After that, there is a subscription fee of $20 per user per month. “That’s like a small cell phone plan,” said Crossley. “It includes support, training and upgrades.”
There are two major reasons why organizations are opting for mobile information systems like VitalHub, said Crossley.
First, they have invested tens of millions of dollars in computerized information systems, only to find that, for the most part, clinicians aren’t using them. She asserted that most electronic health record systems have only a 30 percent usage rate, which is a great disappointment to hospital management.
While the information contained in the systems is extremely useful, it simply takes physicians and nurses too long to get it. “Doctors may have to log into 10 different systems to get at the information they need,” said Crossley. “There are still silos of information that require multiple log-ins, and doctors hate having to waste time searching for the patient information they need. They didn’t go into medicine to spend three hours each day waiting for or working on computers.”
By contrast, VitalHub offers single sign-in and access to all systems. “We’re like an octopus. We sit on top of all of the silos, and our tentacles reach into them.” As a result, there is easy access to the information that physicians and nurses need, she said.
That in turn means clinicians can access patient information right at the bedside, and they can also update the records in real-time. There is no need for doctors to run away searching for a workstation. No need for residents to carry reams of patient printouts to the bedside. And no need for nurses to make handwritten notes of vital signs, only to key them into a workstation an hour later – it can all be done immediately using an iPhone or iPad.
In many cases, real-time access to patient information can make a difference in outcomes, as well. If it takes an hour to obtain information, that data may be outdated or missing critical test results by the time the clinician receives it. Far better to have the real-time access to the databases, said Crossley.
Due to the quick access that VitalHub provides on mobile devices, utilization of the computerized information systems in hospitals soars, said Crossley. That also translates into better outcomes for patients, because of the availability of information.
That value proposition is also powering VitalHub’s entry into the U.S. hospital marketplace, where the company is on the verge of making its first sale. At the time of writing, VitalHub was very close to landing a contract with a 28-hospital healthcare system with facilities in several states.
And while VitalHub was originally focused on connecting to Cerner environments – Mount Sinai Hospital, London Health Sciences and PHSA in BC all run on Cerner information systems – Crossley said that VitalHub can be easily tailored to run on other systems.
Indeed, the U.S. multi-hospital organization that’s about to adopt VitalHub is running four different EHRs – McKesson, Cerner, Meditech and GE Centricity. VitalHub has been shown to work with them all, she said.
Interestingly, the company has produced an additional application called VitalStation, which displays information from multiple sources on a large screen for nursing stations. It gives nurses the status of patients, test results, discharge readiness, and other factors from multiple sources. It’s in use at one nursing station at Mount Sinai and is likely to be rolled out to many others.
In terms of device usage, Crossley commented that physicians are quickly gravitating to the iPad, because the large size of the screen enables them to view more data all at once, and it provides better viewing of diagnostic images. The latest iPad, with its high-resolution Retina screen, is especially good for radiological images.
For their part, nurses seem to like iPhones – the screen is big enough for their needs, and they’re also using it as a nurse call device.
Crossley believes that form factors such as the Samsung Note, which is between the size of a phone and a tablet, may also become popular in medical settings.
The software and interface in the VitalHub are also attractive to users. After signing in, a physician will see his or her patient watchlist, which alerts them to problems that must be dealt with as high priorities. After clicking on the record of a particular patient, a patient dashboard appears, showing all of the relevant data, culled from multiple databases. Click on the various components, and you will continuously drill deeper into the latest results and historical information.
All of this can be customized. “ICU wants to see information in a certain way, and oncology wants it in another way,” said Crossley, who noted this can be further configured for individual doctors and nurses.
The interface is both easy to use and understand. “We can train users in five minutes,” said Crossley. “We’ve done demonstrations where we’ve shown it to doctors and they’ve wanted to start using it in their hospitals immediately. We had to tell them the data and charts were just for demonstration purposes until their hospital purchased our server. But they saw the benefits right away.”
PACS with embedded VR enhances care, in French and in English
In 1997, the hospital faced its toughest challenge, when the Ontario government decided to close the hospital completely as part of a provincial cost-cutting campaign. The facility, along with the local community, rallied to contest the closure, and succeeded in persuading the government to keep Hôpital Montfort open.
In 2005, the Ontario government awarded Montfort over $171 million for a major expansion project, which has now been completed. “We essentially doubled the size of the hospital,” says Dr. Fabiano Taucer, chief of diagnostic imaging at Montfort. Now, the hospital offers 300 beds, and has1,500 employees and 300 doctors.
With the larger facility size came increased expectations. “When we received funding for our expansion, we were asked to predict our anticipated volumes,” explains Dr. Taucer, “and with the expansion complete, we now need to reach those predicted volumes. Our hospital and our department must actively work towards achieving those goals and targets.”
For Hôpital Montfort, and for Dr. Taucer, the Impax solution, incorporating Impax Reporting with speech recognition, plays a significant role in meeting the hospital’s objectives.“Impax has allowed us to significantly decrease our turnaround time,” says Dr. Taucer. “That’s a huge gain in efficiency. Now, the patient comes in, is directed to the modality, the study is immediately available to the radiologist, who can instantly read it, dictate a report with voice recognition, and with the click of a button, it is available system-wide, to the emergency doctors and to the inpatient doctors. There’s no need for any transcription.”
Before Impax, the diagnostic imaging department performed 200 to 250 examinations per day. Now, the department handles 350 to 500 exams per day, equivalent to 300 to 450 patients. There are 11 radiologists, approximately 60 technologists, and about another 20 support staff.
The hospital has a history with Agfa HealthCare that goes back more than two decades. The partnership started with X-ray film, and expanded into digital in 1996 with the installation of the hospital’s first Impax. Initially supporting just CT and ultrasound, the solution was upgraded in 2009 to Impax 6, featuring digital dictation, and now includes all hospital modalities: digital radiography, digital mammography, bone densitometry, sonography, CT, MR and nuclear medicine. “We went virtually overnight from having transcriptionists type our reports to having voice recognition,” says Dr. Taucer.
In selecting the speech recognition technology, a key point for Dr. Taucer and the hospital was Agfa HealthCare’s ability to offer digital dictation in both French and English. As a francophone teaching hospital, supporting French-speaking patients, medical professionals, and students, this aspect was crucial for Montfort. “We need to be able to produce our reports in both official languages and this system can fully support that,” says Dr. Taucer.
Another important factor was integration. “This voice recognition system is completely integrated with Impax. It is not a separate system. This is very important because integration tends to be the most challenging part of working with computers.” The information management capabilities of Impax help Montfort streamline internal processes and meet reporting requirements at the same time.
“In order to become more efficient, we implemented a managerial methodology that we applied to CT, MR, and to ultrasound. To do this, we needed to acquire data in terms of when a study was done, when it was reported, and so on,” says Dr. Taucer.“Impax helps us keep track of these things and makes the data readily available.”
Impax also supplies information that helps Montfort obtain funding. “A provincial government initiative was started several years ago to decrease wait times for certain diagnostic imaging procedures, specifically CT and MR,” says Dr. Taucer. “Some of the data that we need to provide to be eligible for the additional funding is available through Impax.” For Dr. Taucer, the key benefits are linked to improved patient care. “At Montfort, the patient is always at the centre of everything,” he says. “The Impax PACS, along with the reporting solution, has significantly improved our turnaround time. This means our patients can receive a diagnosis faster and start treatment sooner."
Wireless systems are transforming healthcare through fast access to data
Are mobile healthcare technologies at long last ready for the real world? Certainly, there was an impressive array of Canadian and American expert presenters at the ‘8th Annual Mobile Healthcare Summit’, held earlier this year in Toronto. And they testified that, yes, after decades of dreamy pilot projects, mobile technology can and is now doing real, day-in-day-out, productivity-boosting, cost-saving healthcare work.
The Mobile Summit’s two-day program promised to lay out evidence that untethered devices can indeed now:
• enhance care delivery
• optimize workflow
• minimize medical errors
• cut costs
• control privacy and security risks
• improve planning, and
• strengthen infrastructure.
An impressive list, no doubt. But after so many years of mobile technology not winning many battle stars on all those fronts, you could forgive some Summit attendees for remaining skeptical.
“Frankly, I came to this conference to find out if mobile healthcare is still pretty much a myth, or if there is now some real magic in it,” volunteered Dan Coghlan, the vice-president of finance and information management for Providence Care, a specialized provider of mental health and geriatric care in Kingston, Ont.
Conference chair and keynote speaker, Dr. John Mattison of California-based Kaiser Permanente, immediately pointed out some magical applications of wireless technology. As Kaiser Permanente’s chief medical information officer and also its assistant medical director, Dr. Mattison has been developing and implementing for two decades now innovative mobile technology solutions for America’s largest health management organization (HMO) and the nearly nine million health plan members the HMO looks after.
Perhaps most widely known as the founder of HL7 clinical document architecture, the international standard for medical data interchange, Dr. Mattison has been instrumental in developing the likes of a text messaging system and a smartphone app so KP members can book appointments on the fly. Most recently, he’s been co-ordinating a country-wide project to introduce iPads into Kaiser’s patient and out-patient workflows.
“The mobile opportunity has opened the door for some of the most disruptive healthcare technologies of our time,” said Dr. Mattison in his opening remarks. “For example, at Kaiser Permanente we’ve taken steps to connect doctors and their patients directly with each other via email. So starting this morning as I speak, for instance, there will be approximately 25,000 doctor-patient email exchanges before this day is out. Those kind of exchanges at Kaiser Permanente are taking off like wildfire.”
Dr. Mattison proffered some other remarkable numbers that got the Summit off to an optimistic start. In the next five years, he said, another one billion more people will have internet access, swelling the ranks of the 2.2 billion folks estimated by Internet World Stats to have access now. Many, if not most, will be using mobile smartphones as their tool of entry.
That could well be good news for Dr. Patricia Mechael, the executive director of the United Nation Foundation’s globe-girdling mobile health organization called mHealth Alliance, headquartered in Washington, D.C. At the Toronto Summit, Dr. Mechael was quick to the dais when introduced – all the more admirably so since she was visibly pregnant.
“Patricia for the past 15 years has been helping women and children, among others in Africa, the Middle East, Asia and in developing countries all over the world, for much of the time using eHealth and mHealth technologies,” said Dr. Mattison in his introduction.
Dr. Mechael graciously began her presentation with a compliment to her hosts: “It’s an honour to be here because Canada has been a lighthouse for us in terms of using technology. In the work we do, we regularly look at Canada to see what we can apply to developing countries.”
But Mechael soon added that we in the developed countries may now have something to learn in return from how extensively developing countries are using cell phone technology to advance healthcare in their hinterlands.
“I’ve been researching the subject for about the past 11 years now. And the way cell phones have evolved and emerged in developing countries has brought new meaning to the way people access health services; how they access health information; and how they interact with each other,” said Mechael.
“In Africa, Asia, and Latin America there’s almost now a ratio of one-to-one cell phones to people,” said Mechael. “And that’s not something even the most optimistic telecom companies would have predicted ten years ago. But what they and really all of us missed was that people in those regions made the cell phone a personal priority, not because they wanted more and better information, but because they simply wanted to communicate with others. They wanted to feel connected.”
And health authorities are evidently learning fast how to take advantage of that need.
“In effect,” said Mechael, “they are reaching out via their cell phone systems and giving their people a virtual healthcare hug.”
“There is a persistent problem in developing countries of a high infant mortality rate,” said Mechael. “But motherhood is such a complex issue. It cuts across education, nutrition, and healthcare.”
So both better information about, and better access to, healthcare are crucial if more infants are to survive. To that end, the mHealth Alliance in Washington is a partner in the MAMA program.
“It’s the Mobile Alliance for Maternal Action,” explains Mechael, “and it focuses on the use of interactive voice recognition, text messaging, and the global web as conveyors of information to pregnant women. MAMA is starting up first in Bangladesh, South Africa, and India.”
But as Mechael points out, MAMA is not alone in efforts to make mHealth serve the under-served. “The Harvard School of Public Health is working with the health ministry of Tanzania and looking at the use of mobile technologies in decision support. They are creating algorithms for case workers in the field so that they can make informed decisions on the spot about the cases they are managing.”
Specifically, the calculated set of rules in their cell phones will better equip remote Tanzanian caregivers to diagnose and deal with the likes of childhood illness, malaria, and diarrheal diseases so common in developing countries.
“In a way, those decentralized health workers are being given a sort of peripheral brain,” observed Mechael.
Developing countries are also taking a world lead in using mobile technology for improved disease and epidemic outbreak tracking.
“China does a lot of that kind of tracking now on the heels of its avian flu and SARS outbreaks,” said Mechael. “More recently, cell phones are being used to track the cholera outbreak in Haiti.”
On a more global scale of tracking, is an initiative called RapidSMS.
“It’s an open source SMS-based reporting tool developed by the UNICEF innovations group for use in the developing world and it’s now being used in a wide range of countries, but especially in Africa,” explained Mechael. “It was first put to use for nutrition tracking in Malawi (where 22 percent of children under age five are underweight), but now it’s being used to track 14 reportable diseases in Uganda with other countries to follow.”
RapidSMS has made disease tracking data transmission much of it over mobile technology not only more accurate but exponentially faster. What used to take up to three months to collect data from a paper-based system can now be done in two minutes, or 64,800 times quicker.
Magical you might say.
There’s something majestic, if not magical, about another text-based system supported by Mechael and the mHealth Alliance called “SMS for Life”.
“It is a supply chain management system and medical supply chains are a big problem in developing countries,” said Mechael. “I had a personal experience when I was working with a clinic in Uganda. A severely dehydrated child came in who really only needed a five-cent rehydration treatment. However, the clinic had stocked out of the treatment and so the child had to be transported to another clinic for what amounted to a $150 dollar treatment.”
Currently SMS for Life is is striving to save some of the 660,000 people worldwide who die from malaria.
In its initial 21-week pilot program, Mechael reported that SMS for Life reduced malarial drug stock-outs from 26 percent down to a near-zero 0.8 percent. The application is now being applied to other supplies, including diagnostic tests and blood supplies in sub-Saharan countries where there’s little telecommunication except by cell phone.
The African sub-Sahara is a long way both geographically, culturally, and healthcare-wise from the Toronto suburb of North York, where Sandy Saggar goes to work every day as director of information technology and clinical informatics for North York General Hospital.
And yet both have a problem in common with much of the rest of the world – medication errors. As Mr. Saggar told his audience at the Mobile Health Summit, the three-site, 613-bed North York General Hospital chose to tackle medical errors with the help of Motorola Solutions. They are using a wireless LAN network linking a plethora of point-of-care mobile devices including medication carts, laptops, cell phones, and other handheld devices on which caregivers can submit data. “They are all part of an initiative we began rolling out in 2008 called “eCare”, which includes an advanced electronic medical record; standardized, evidence-based care, clinical decision support, and safe prescribing and medication administration, all aimed at improving patient outcomes.”
The effort has won North York General a HIMSS (Healthcare Information and Management Systems Society) Stage 6 ranking for its EMR readiness, making North York just one of three Canadian hospitals to gain that exalted level. That achievement is built on two powerful point-of-care applications that rely on mobile devices: one computerizes physician entry of orders and the other is a bar-code based, medication admin system. Together they serve to significantly reduce medication errors.
Saggar explained that the system positively identifies a patient before any medication is administered, catching a potential error before it becomes one: “In its first year of operation, after the go-live at North York, our eCare solution helped catch and rectify more than 1,300 instances in which patients could have been given the wrong medication.
But if there is now such magic in wireless and mobile technologies, they don’t come without risk. That was made clear early by Dr. Khaled El Emam, PhD. Dr. Khaled wears many hats, including that of an associate professor at the University of Ottawa’s Faculty of Medicine, and of the Canada Research Chair at the Children’s Hospital of Eastern Ontario (CHEO). But partly from earlier work at Germany’s renowned Fraunhofer Institute, he is known worldwide for the public health techniques he has researched and developed for making health data anonymous and for keeping a watch on disease outbreaks.
“Mobile devices can improve your organizational efficiency and enhance patient care, certainly,” Dr. El Emam told his Summit audience. “However, privacy and security risks are a reality that needs to be top of mind when considering your organization’s next mobile health initiative – especially when physician-owned devices are involved.”
Dr. El Emam went on to cite several reliable studies of breaches in healthcare privacy and security.
“The first study you should note is an American one that showed over half the healthcare security and privacy breaches it examined were the result of either the loss or the theft of a mobile device,” said El Emam. “And another similar survey showed that loss or theft of mobile devices had compromised the security of over two million patient records.”
And those compromised records come at a heavy cost. “In most healthcare jurisdictions now there’s a reporting procedure that must be followed whenever there is a privacy or security breach of confidential healthcare information,” said El Emam. “It’s not cheap to notify thousands of patients, of course, and then there are the inevitable litigation costs. Also the organizations responsible for preventing such breaches are usually penalized severely.”
El Emam pointed out that Massachusetts General in Boston, one of America’s most respected hospitals, had nonetheless been fined $4 million for a bad breach of its records.
“The average across multiple studies is that for compromised records, the cost to the record-keeper ends up between $200 and $300 per record,” said Emam. “Now you have a figure that you can use to calculate how much you want to spend on risk mitigation, considering the number of records you hold.”
El Emam said his research, done with the aid of privacy commissioners throughout North America, the FDA in the United States and others in the know, suggest there are about a dozen risk mitigating safeguards you are best to spend your money on if mobile devices are going to be at the centre of your new eHealth strategy.
Among the basic and important ones are:
• set things up so you allow remote access to your data rather than allowing data to be stored on mobile devices. So even if the device is lost or stolen, there is no breach.
• put automatic locking on remote devices so that they are inaccessible after only a few minutes of non-use, as aggravating as that might be to the caregivers using the device who must then re-enter their passwords.
• be aware that even a person’s date of birth and postal code can tell a less-than-ethical lawyer, insurance investigator, blackmailer, or other snoop, who that person is from publicly available records.
• make sure that you can delete data remotely from your mobile devices, so that whenever a device is reported lost or stolen you can tell the IT department to press the kill switch and wipe out any data or internet access capabilities on the device, no matter where it is.
• make sure all your devices are encrypted all the time, even if they are big desk tops, especially ones on the ground floor near a window. That makes it easy for thieves to do a smash-and-grab.
• ensure you institute a well-understood policy that any loss or theft of a mobile device is reported immediately. The first thing you want to do with any breach, of course, is to close it.
“These are all very basic, seemingly obvious things to do, I know, but it is amazing how often we find among those using mobile technology in healthcare that they are not being done,” said El Emam.
Toronto’s UHN rolls out self-care kiosks for chronic kidney disease
CTORONTO – Last year, the University Health Network’s Division of Nephrology launched MyKidneyCare centre, a web based, self-management station for patients that focuses on educating patients about chronic kidney disease. It enables patients to monitor their CKD progress, and encourages them to set learning goals.
The system also provides a tool to facilitate patient collaboration with their
The application was first piloted in the waiting rooms of three ambulatory nephrology clinics as touch-screen self-assessment kiosks. With continuous feedback from patients and clinicians, the project team has redesigned and enhanced the application and extended its use to nearly 10 clinics and all pre-dialysis patients at the Toronto General Hospital.
The MyKidneyCare centre kiosk is available in English, Chinese and Italian to serve various populations that the clinics see. Patients use the kiosk to perform self assessments using the Edmonton symptom assessment scale (ESAS) tool to track their CKD symptoms, to document their health issues and concerns, to identify team members they want to see and to select learning topics of interest.
When using the kiosk, patients are asked if they want to see, as part of their visit, a dietician, pharmacist, social worker, chiropodist, or a kidney foundation peer support coordinator, in addition to the doctor and nurse.
The can also alert clinicians to the state of their health by answering questions about eating and diet, medications, work, school and family, and their wellness, in general.
They can flip through educational screens that tell them more about kidney functions, blood and urine tests, diseases related to kidney problems, medications, blood pressure and sugar control. What’s more, they can always answer that they’re not ready to learn more at the time of their visits.
Clinicians can view the patients’ responses in their clinic rooms from their computer terminals. When the patients arrive in the clinic assessment rooms, a summary of the patient’s self assessment report is made available.
Clinicians also have an opportunity to view a trend of response from previous visits, which allows them to monitor and track the progress made by patients. At the end of the visit, patients are given a printout that summarizes the encounter, and serves as an easy-to-consult reminder of their learning needs and the ‘take-home’ messages from each clinician.
The MyKidneyCare centre kiosk is designed to increase the patients’ involvement in their own treatment. It helps them identify their individual health needs and also facilitates the process of collaborating with clinicians during their visits.
With take home messages, patients and caregivers have the opportunity to stay engaged and actively participate in treatment plans outside the healthcare setting, which is vital in chronic disease management. Chronic kidney disease is a complex condition which requires contact with multiple clinicians, follow up at home and active participation in care.
To date, the kiosk has over 400 registered patients across the 10 ambulatory nephrology clinics. A preliminary user-satisfaction survey indicates that both patients and staff felt that the kiosk added value to the quality of the visits and strengthen patient-provider relationships. And although the majority of the kiosk users were aged 61 to 70 years old, 75 percent did not feel the kiosk was difficult to use.
Some examples of patient experiences of the kiosk are included in the following survey feedback:
• “Having the option of who you want to see and what you want to learn. It is informative.”
• “It listed a number of options about what information you wanted, you could choose more than one option and it’s an efficient way to get answers.”
• “Listing all my symptoms gives them a better idea of how to treat you properly”
• “It can help the doctor understand my situation quicker.”
A national survey of Canadian nephrology programs indicates MyKidneyCare centre is the first of its kind in Canada for CKD patients.
To increase adoption and accessibility, the My Kidney Care centre application will be expanded to be used on other mobile media devices, such as tablets and smartphones and other chronic disease states. Given the increasing burden of chronic disease management today, adoption of patient-centric and easy to use IT solutions which support patient self management are integral to optimize healthcare delivery for these patients.
Those who are interested in learning more about MyKidneyCare may contact Dr. Judith Miller, Director, Division of Nephrology at University Health Network.
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